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Miller AL, Evanson NK, Taylor JM. Use of donepezil for neurocognitive recovery after brain injury in adult and pediatric populations: a scoping review. Neural Regen Res 2024; 19:1686-1695. [PMID: 38103232 PMCID: PMC10960296 DOI: 10.4103/1673-5374.389628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/07/2023] [Accepted: 11/01/2023] [Indexed: 12/18/2023] Open
Abstract
There are few pharmacologic options for the treatment of cognitive deficits associated with traumatic brain injury in pediatric patients. Acetylcholinesterase inhibitors such as donepezil have been evaluated in adult patients after traumatic brain injury, but relatively less is known about the effect in pediatric populations. The goal of this review is to identify knowledge gaps in the efficacy and safety of acetylcholinesterase inhibitors as a potential adjuvant treatment for neurocognitive decline in pediatric patients with traumatic brain injury. Investigators queried PubMed to identify literature published from database inception through June 2023 describing the use of donepezil in young adult traumatic brain injury and pediatric patients with predefined conditions. Based on preselected search criteria, 340 unique papers were selected for title and abstract screening. Thirty-two records were reviewed in full after eliminating preclinical studies and papers outside the scope of the project. In adult traumatic brain injury, we review results from 14 papers detailing 227 subjects where evidence suggests donepezil is well tolerated and shows both objective and patient-reported efficacy for reducing cognitive impairment. In children, 3 papers report on 5 children recovering from traumatic brain injury, showing limited efficacy. An additional 15 pediatric studies conducted in populations at risk for cognitive dysfunction provide a broader look at safety and efficacy in 210 patients in the pediatric age group. Given its promise for efficacy in adults with traumatic brain injury and tolerability in pediatric patients, we believe further study of donepezil for children and adolescents with traumatic brain injury is warranted.
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Affiliation(s)
- Avery L. Miller
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nathan K. Evanson
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J. Michael Taylor
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Watkins LV, Moon S, Burrows L, Tromans S, Barwell J, Shankar R. Pharmacological management of fragile X syndrome: a systematic review and narrative summary of the current evidence. Expert Opin Pharmacother 2024; 25:301-313. [PMID: 38393835 DOI: 10.1080/14656566.2024.2323605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/22/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Fragile X syndrome (FXS) is the most common inherited cause of Intellectual Disability. There is a broad phenotype that includes deficits in cognition and behavioral changes, alongside physical characteristics. Phenotype depends upon the level of mutation in the FMR1 (fragile X messenger ribonucleoprotein 1) gene. The molecular understanding of the impact of the FMR1 gene mutation provides an opportunity to target treatment not only at symptoms but also on a molecular level. METHODS We conducted a systematic review to provide an up-to-date narrative summary of the current evidence for pharmacological treatment in FXS. The review was restricted to randomized, blinded, placebo-controlled trials. RESULTS The outcomes from these studies are discussed and the level of evidence assessed against validated criteria. The initial search identified 2377 articles, of which 16 were included in the final analysis. CONCLUSION Based on this review to date there is limited data to support any specific pharmacological treatments, although the data for cannabinoids are encouraging in those with FXS and in future developments in gene therapy may provide the answer to the search for precision medicine. Treatment must be person-centered and consider the combination of medical, genetic, cognitive, and emotional challenges.
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Affiliation(s)
- Lance V Watkins
- Epilepsy Specialist Service, Swansea Bay University Health Board, Cardiff, UK
- Unit for Development in Intellectual and Developmental Disabilities, University of South Wales, Pontypridd, UK
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
| | - Seungyoun Moon
- Epilepsy Specialist Service, Swansea Bay University Health Board, Cardiff, UK
| | - Lisa Burrows
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
- Adult Neurodevelopmental Psychiatry, Cornwall Partnership NHS Trust, Truro, UK
| | - Samuel Tromans
- Department of Population Health Sciences, University of Leicester, Leicester, UK
- Adult Learning Disability Service, Leicestershire Partnership NHS Trust, Leicester, UK
| | - Julian Barwell
- Clinical Genetics Department, University Hospitals of Leicester, Leicester, UK
| | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
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Wu C, Gaier ED, Nihalani BR, Whitecross S, Hensch TK, Hunter DG. Durable recovery from amblyopia with donepezil. Sci Rep 2023; 13:10161. [PMID: 37349338 PMCID: PMC10287641 DOI: 10.1038/s41598-023-34891-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/09/2023] [Indexed: 06/24/2023] Open
Abstract
An elevated threshold for neuroplasticity limits visual gains with treatment of residual amblyopia in older children and adults. Acetylcholinesterase inhibitors (AChEI) can enable visual neuroplasticity and promote recovery from amblyopia in adult mice. Motivated by these promising findings, we sought to determine whether donepezil, a commercially available AChEI, can enable recovery in older children and adults with residual amblyopia. In this open-label pilot efficacy study, 16 participants (mean age 16 years; range 9-37 years) with residual anisometropic and/or strabismic amblyopia were treated with daily oral donepezil for 12 weeks. Donepezil dosage was started at 2.5 or 5.0 mg based on age and increased by 2.5 mg if the amblyopic eye visual acuity did not improve by 1 line from the visit 4 weeks prior for a maximum dosage of 7.5 or 10 mg. Participants < 18 years of age further patched the dominant eye. The primary outcome was visual acuity in the amblyopic eye at 22 weeks, 10 weeks after treatment was discontinued. Mean amblyopic eye visual acuity improved 1.2 lines (range 0.0-3.0), and 4/16 (25%) improved by ≥ 2 lines after 12 weeks of treatment. Gains were maintained 10 weeks after cessation of donepezil and were similar for children and adults. Adverse events were mild and self-limited. Residual amblyopia improves in older children and adults treated with donepezil, supporting the concept that the critical window of visual cortical plasticity can be pharmacologically manipulated to treat amblyopia. Placebo-controlled studies are needed.
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Affiliation(s)
- Carolyn Wu
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA.
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
| | - Eric D Gaier
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Bharti R Nihalani
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
| | - Takao K Hensch
- Center for Brain Science, Department of Molecular Cellular Biology, Harvard University, Cambridge, MA, USA
- International Research Center for Neurointelligence, University of Tokyo Institutes for Advanced Study, Tokyo, Japan
- FM Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David G Hunter
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- International Research Center for Neurointelligence, University of Tokyo Institutes for Advanced Study, Tokyo, Japan
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Ure A, Cox GR, Haslam R, Williams K. Acetylcholinesterase inhibitors for autistic spectrum disorders. Cochrane Database Syst Rev 2023; 6:CD013851. [PMID: 37267443 PMCID: PMC10233795 DOI: 10.1002/14651858.cd013851.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side-effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. OBJECTIVES To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non-core features of autism. SEARCH METHODS In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. SELECTION CRITERIA Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. MAIN RESULTS We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low-certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) -2.75, 95% confidence interval (CI) -5.88 to 0.38), and restricted and repetitive behaviour (MD -0.55, 95% CI -3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low-certainty evidence. No serious adverse events were reported. Low-certainty evidence showed a small difference in irritability (MD -3.50, 95% CI -6.39 to -0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD -5.20, 95% CI -10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low-certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI -0.19 to 0.33), or in the autism symptom domains of social communication (MD -0.02, 95% CI -0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI -0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI -0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI -0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low-certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. AUTHORS' CONCLUSIONS Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence.
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Affiliation(s)
- Alexandra Ure
- Department of Paediatrics, Monash University, Melbourne, Australia
- Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Georgina R Cox
- Department of Paediatrics, Monash University, Melbourne, Australia
- Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia
| | - Richard Haslam
- Mental Health Department, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Melbourne, Australia
- Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
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5
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Falk EN, Norman KJ, Garkun Y, Demars MP, Im S, Taccheri G, Short J, Caro K, McCraney SE, Cho C, Smith MR, Lin HM, Koike H, Bateh J, Maccario P, Waltrip L, Janis M, Morishita H. Nicotinic regulation of local and long-range input balance drives top-down attentional circuit maturation. SCIENCE ADVANCES 2021; 7:eabe1527. [PMID: 33674307 PMCID: PMC7935362 DOI: 10.1126/sciadv.abe1527] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/21/2021] [Indexed: 06/12/2023]
Abstract
Cognitive function depends on frontal cortex development; however, the mechanisms driving this process are poorly understood. Here, we identify that dynamic regulation of the nicotinic cholinergic system is a key driver of attentional circuit maturation associated with top-down frontal neurons projecting to visual cortex. The top-down neurons receive robust cholinergic inputs, but their nicotinic tone decreases following adolescence by increasing expression of a nicotinic brake, Lynx1 Lynx1 shifts a balance between local and long-range inputs onto top-down frontal neurons following adolescence and promotes the establishment of attentional behavior in adulthood. This key maturational process is disrupted in a mouse model of fragile X syndrome but was rescued by a suppression of nicotinic tone through the introduction of Lynx1 in top-down projections. Nicotinic signaling may serve as a target to rebalance local/long-range balance and treat cognitive deficits in neurodevelopmental disorders.
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Affiliation(s)
- Elisa N Falk
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Kevin J Norman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Yury Garkun
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Michael P Demars
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Susanna Im
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Giulia Taccheri
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Jenna Short
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Keaven Caro
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Sarah E McCraney
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Christina Cho
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Milo R Smith
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Hiroyuki Koike
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Julia Bateh
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Priscilla Maccario
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Leah Waltrip
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Meaghan Janis
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Hirofumi Morishita
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
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6
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Abstract
Autism is a grand challenge in global mental health to be dealt with on a priority basis. Phenotypic knowledge, biological understanding, and evidence-based intervention studies are all from western countries. We know very little about autism in the low- and middle-income countries (LMIC). Lack of infrastructure and difficulties in operationalizing research has widened the knowledge gap. We performed a comprehensive scoping review of research in Autism Spectrum Disorder in India to have an overall impression, identify gaps, and formulate evidence-based recommendations for further study. We searched PubMed, SCOPUS, and Cochrane Library to identify relevant Indian studies. A hundred and fifty-nine publications met the inclusion criteria. Most of the research contribution in autism is from few tertiary care medical centres, technological institutes, and not-for-profit organizations. We identified various themes of research like clinical profile, interventions, biomarkers, psychological, social, epidemiological, and risk factors. Evidence-based intervention studies, translation and adaptation of standard diagnostic instruments, and qualitative research on the experience of autism appeared to be state of the art. However, epidemiological studies, biomarkers identification, risk assessment studies were of low quality. There is a need for nationwide studies with representative sampling on epidemiology, biomarkers, and risk factors for a complete evaluation of the actual burden and biology of autism in India. Also, there is a need to design implementation research to evaluate the effectiveness of evidence-based interventions in routine healthcare settings. We recommend that future research should fill these gaps in understanding autism and improving its outcome in India.
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Affiliation(s)
- Suravi Patra
- Department of Psychiatry, All India Institute of Medical Sciences Bhubaneswar, Odisha, India
| | - Sujita Kumar Kar
- Department of Psychiatry, King George Medical University, Lucknow, Uttar Pradesh, India
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7
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Cox GR, Williams K, Woon JM, Haslam R, Ure A. Acetylcholinesterase inhibitors for autistic spectrum disorders. Hippokratia 2021. [DOI: 10.1002/14651858.cd013851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Georgina R Cox
- Department of Paediatrics; Monash University; Melbourne Australia
- Neurodevelopment and Disability; The Royal Children's Hospital; Melbourne Australia
| | - Katrina Williams
- Department of Paediatrics; Monash University; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
- Developmental Paediatrics; Monash Children's Hospital; Melbourne Australia
- Murdoch Children's Research Institute; Melbourne Australia
| | - Jade M Woon
- Neurodevelopment and Disability; The Royal Children's Hospital; Melbourne Australia
| | - Richard Haslam
- Mental Health Department; The Royal Children's Hospital; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
| | - Alexandra Ure
- Department of Paediatrics; Monash University; Melbourne Australia
- Mental Health Department; The Royal Children's Hospital; Melbourne Australia
- Developmental Paediatrics; Monash Children's Hospital; Melbourne Australia
- Murdoch Children's Research Institute; Melbourne Australia
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8
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Dávila G, Moyano MP, Edelkraut L, Moreno-Campos L, Berthier ML, Torres-Prioris MJ, López-Barroso D. Pharmacotherapy of Traumatic Childhood Aphasia: Beneficial Effects of Donepezil Alone and Combined With Intensive Naming Therapy. Front Pharmacol 2020; 11:1144. [PMID: 32848757 PMCID: PMC7411310 DOI: 10.3389/fphar.2020.01144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 07/13/2020] [Indexed: 12/14/2022] Open
Abstract
At present, language therapy is the only available treatment for childhood aphasia (CA). Studying new interventions to augment and hasten the benefits provided by language therapy in children is strongly needed. CA frequently emerges as a consequence of traumatic brain injury and, as in the case of adults, it may be associated with dysfunctional activity of neurotransmitter systems. The use of cognitive-enhancing drugs, alone or combined with aphasia therapy, promotes improvement of language deficits in aphasic adults. In this study we report the case of a 9-year-old right-handed girl, subject P, who had chronic anomic aphasia associated with traumatic lesions in the left temporal-parietal cortex. We performed a single-subject, open-label study encompassing administration of the cholinergic agent donepezil (DP) alone during 12 weeks, followed by a combination of DP and intensive naming therapy (INT) for 2 weeks and thereafter by a continued treatment of DP alone during 12 weeks, a 4-week washout period, and another 2 weeks of INT. Four comprehensive language and neuropsychological evaluations were performed at different timepoints along the study, and multiple naming evaluations were performed after each INT in order to assess performance in treated and untreated words. Structural magnetic resonance imaging (MRI) was performed at baseline. MRI revealed two focal lesions in the left hemisphere, one large involving the posterior inferior and middle temporal gyri and another comprising the angular gyrus. Overall, baseline evaluation disclosed marked impairment in naming with mild-to-moderate compromise of spontaneous speech, repetition, and auditory comprehension. Executive and attention functions were also affected, but memory, visuoconstructive, and visuoperceptive functions were preserved. Treatment with DP alone significantly improved spontaneous speech, auditory comprehension, repetition, and picture naming, in addition to processing speed, selective, and sustained attention. Combined DP-INT further improved naming. After washout of both interventions, most of these beneficial changes remained. Importantly, DP produced no side effects and subject P attained the necessary level of language competence to return to regular schooling. In conclusion, the use of DP alone and in combination with INT improved language function and related cognitive posttraumatic deficits in a child with acquired aphasia. Further studies in larger samples are warranted.
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Affiliation(s)
- Guadalupe Dávila
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Malaga, Spain.,Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain.,Department of Psychobiology and Methodology of Behavioural Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain.,Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - María Pilar Moyano
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Malaga, Spain
| | - Lisa Edelkraut
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Malaga, Spain.,Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain.,Department of Psychobiology and Methodology of Behavioural Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain.,Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - Lorena Moreno-Campos
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Malaga, Spain
| | - Marcelo L Berthier
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Malaga, Spain.,Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain.,Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - María José Torres-Prioris
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Malaga, Spain.,Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain.,Department of Psychobiology and Methodology of Behavioural Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain.,Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - Diana López-Barroso
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Malaga, Spain.,Instituto de Investigación Biomédica de Málaga - IBIMA, Málaga, Spain.,Department of Psychobiology and Methodology of Behavioural Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain.,Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
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9
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Telias M. Pharmacological Treatments for Fragile X Syndrome Based on Synaptic Dysfunction. Curr Pharm Des 2020; 25:4394-4404. [PMID: 31682210 DOI: 10.2174/1381612825666191102165206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 10/31/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fragile X syndrome (FXS) is the most common form of monogenic hereditary cognitive impairment, including intellectual disability, autism, hyperactivity, and epilepsy. METHODS This article reviews the literature pertaining to the role of synaptic dysfunction in FXS. RESULTS In FXS, synaptic dysfunction alters the excitation-inhibition ratio, dysregulating molecular and cellular processes underlying cognition, learning, memory, and social behavior. Decades of research have yielded important hypotheses that could explain, at least in part, the development of these neurological disorders in FXS patients. However, the main goal of translating lab research in animal models to pharmacological treatments in the clinic has been so far largely unsuccessful, leaving FXS a still incurable disease. CONCLUSION In this concise review, we summarize and analyze the main hypotheses proposed to explain synaptic dysregulation in FXS, by reviewing the scientific evidence that led to pharmaceutical clinical trials and their outcome.
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Affiliation(s)
- Michael Telias
- Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA, United States
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10
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Postmortem Studies of Neuroinflammation in Autism Spectrum Disorder: a Systematic Review. Mol Neurobiol 2020; 57:3424-3438. [DOI: 10.1007/s12035-020-01976-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/02/2020] [Indexed: 02/06/2023]
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11
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Bruno JL, Hosseini SH, Lightbody AA, Manchanda MK, Reiss AL. Brain circuitry, behavior, and cognition: A randomized placebo-controlled trial of donepezil in fragile X syndrome. J Psychopharmacol 2019; 33:975-985. [PMID: 31264943 PMCID: PMC6894490 DOI: 10.1177/0269881119858304] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Fragile X syndrome, the most common inherited cause for intellectual disability, is associated with alterations in cholinergic among other neurotransmitter systems. This study investigated the effects of donepezil hydrochloride, a cholinesterase inhibitor that has potential to correct aberrant cholinergic signaling. METHOD Forty-two individuals with fragile X syndrome (mean age=19.61 years) were randomized to receive 2.5-10.0 mg of donepezil (n=20, seven females) or placebo (n=22, eight females) per day. One individual in the active group withdrew at week 7. Outcomes included the contingency naming test, the aberrant behavior checklist, and behavior and brain activation patterns during a functional magnetic resonance imaging gaze discrimination task. RESULTS There were no significant differences between active and placebo groups on cognitive (contingency naming task) or behavioral (total score or subscales of the aberrant behavior checklist) outcomes. At baseline, the active and placebo groups did not differ in functional magnetic resonance imaging activation patterns during the gaze task. After 12 weeks of treatment the active group displayed reduced activation in response to the averted vs direct gaze contrast, relative to the placebo group, in the left superior frontal gyrus. CONCLUSIONS Reduced functional brain activation for the active group may represent less arousal in response to direct eye gaze, relative to the placebo group. Change in functional magnetic resonance imaging activation patterns may serve as a more sensitive metric and predictor of response to treatment when compared to cognitive and behavioral assessments. Our results suggest that donepezil may have an impact on brain functioning, but longer term follow-up and concomitant behavioral intervention may be required to demonstrate improvement in cognition and behavior.
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Affiliation(s)
- Jennifer L. Bruno
- Center for Interdisciplinary Brain Sciences Research, Stanford University.,To whom correspondence should be addressed: 401 Quarry Road, Palo Alto, CA 94304, Phone: 818-415-9119, Fax: (650) 724-4761,
| | - S.M. Hadi Hosseini
- Center for Interdisciplinary Brain Sciences Research, Stanford University
| | - Amy A. Lightbody
- Center for Interdisciplinary Brain Sciences Research, Stanford University
| | - Mai K. Manchanda
- Center for Interdisciplinary Brain Sciences Research, Stanford University
| | - Allan L. Reiss
- Center for Interdisciplinary Brain Sciences Research, Stanford University.,Department of Radiology, Stanford University.,Department of Pediatrics, Stanford University
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12
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A systematic review of tools used to screen and assess for externalising behaviour symptoms in low and middle income settings. Glob Ment Health (Camb) 2019; 6:e13. [PMID: 31391945 PMCID: PMC6669966 DOI: 10.1017/gmh.2019.11] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 05/05/2019] [Accepted: 06/01/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Mental health issues, often manifested as behavioural difficulties, in children are estimated to be high in low and middle-income countries (LMIC) settings. There is a paucity of definitive data due to a lack of well-validated tools to use across settings. This review aims to provide evidence on what tools are used and which have been adapted and validated in LMIC settings. METHODS We performed a systematic review to identify tools used to assess or screen externalising behaviour problems in children and adolescents in LMIC and assess their cultural adaptations. We searched for studies measuring externalising behaviour in children from 0 to 19 years published up to September 2018. Articles were assessed to identify tools used and analysed using the Ecological Validity Framework. RESULTS We identified 82 articles from over 50 LMICs who had studied externalising behaviour in children. Twenty-seven tools were identified, with a predominance of studies using tools from the USA and Europe. Most studies did not describe an adaptation and evaluation process, with only one study following recommended criteria. New tools were identified which both screen and assess externalising behaviour which have not yet been utilised across settings. CONCLUSIONS Although tools from the USA and Europe are often utilised to screen and assess for externalising behaviour problems in children in LMICs, the conceptual frameworks behind the use of these tools in other cultural contexts are not always carefully examined. In order to have valid data across cultures, we should aim to adapt and validate tools before use. Provision of processes to validate tools across LMIC settings would be beneficial.
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13
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Gładysz D, Krzywdzińska A, Hozyasz KK. Immune Abnormalities in Autism Spectrum Disorder-Could They Hold Promise for Causative Treatment? Mol Neurobiol 2018; 55:6387-6435. [PMID: 29307081 PMCID: PMC6061181 DOI: 10.1007/s12035-017-0822-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/05/2017] [Indexed: 12/15/2022]
Abstract
Autism spectrum disorders (ASD) are characterized by impairments in language and communication development, social behavior, and the occurrence of stereotypic patterns of behavior and interests. Despite substantial speculation about causes of ASD, its exact etiology remains unknown. Recent studies highlight a link between immune dysfunction and behavioral traits. Various immune anomalies, including humoral and cellular immunity along with abnormalities at the molecular level, have been reported. There is evidence of altered immune function both in cerebrospinal fluid and peripheral blood. Several studies hypothesize a role for neuroinflammation in ASD and are supported by brain tissue and cerebrospinal fluid analysis, as well as evidence of microglial activation. It has been shown that immune abnormalities occur in a substantial number of individuals with ASD. Identifying subgroups with immune system dysregulation and linking specific cellular immunophenotypes to different symptoms would be key to defining a group of patients with immune abnormalities as a major etiology underlying behavioral symptoms. These determinations would provide the opportunity to investigate causative treatments for a defined patient group that may specifically benefit from such an approach. This review summarizes recent insights into immune system dysfunction in individuals with ASD and discusses the potential implications for future therapies.
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Affiliation(s)
- Dominika Gładysz
- Department of Pediatrics, Institute of Mother and Child, Warsaw, Poland
| | | | - Kamil K Hozyasz
- Department of Pediatrics, Institute of Mother and Child, Warsaw, Poland.
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14
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Tranfaglia MR, Thibodeaux C, Mason DJ, Brown D, Roberts I, Smith R, Guilliams T, Cogram P. Repurposing available drugs for neurodevelopmental disorders: The fragile X experience. Neuropharmacology 2018; 147:74-86. [PMID: 29792283 DOI: 10.1016/j.neuropharm.2018.05.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 10/17/2022]
Abstract
Many available drugs have been repurposed as treatments for neurodevelopmental disorders. In the specific case of fragile X syndrome, many clinical trials of available drugs have been conducted with the goal of disease modification. In some cases, detailed understanding of basic disease mechanisms has guided the choice of drugs for clinical trials, and several notable successes in fragile X clinical trials have led to common use of drugs such as minocycline in routine medical practice. Newer technologies like Disease-Gene Expression Matching (DGEM) may allow for more rapid identification of promising repurposing candidates. A DGEM study predicted that sulindac could be therapeutic for fragile X, and subsequent preclinical validation studies have shown promising results. The use of combinations of available drugs and nutraceuticals has the potential to greatly expand the options for repurposing, and may even be a viable business strategy. This article is part of the Special Issue entitled 'Drug Repurposing: old molecules, new ways to fast track drug discovery and development for CNS disorders'.
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Affiliation(s)
| | - Clare Thibodeaux
- Cures Within Reach, 125 S. Clark Street, 17th Floor, Chicago, IL 60603, USA.
| | - Daniel J Mason
- Healx Ltd., Park House, Castle Park, Cambridge, CB3 0DU, United Kingdom.
| | - David Brown
- Healx Ltd., Park House, Castle Park, Cambridge, CB3 0DU, United Kingdom
| | - Ian Roberts
- Healx Ltd., Park House, Castle Park, Cambridge, CB3 0DU, United Kingdom
| | - Richard Smith
- Healx Ltd., Park House, Castle Park, Cambridge, CB3 0DU, United Kingdom
| | - Tim Guilliams
- Healx Ltd., Park House, Castle Park, Cambridge, CB3 0DU, United Kingdom
| | - Patricia Cogram
- FRAXA-DVI, IEB, Las Encinas 3370, Ñuñoa, Santiago, Chile; Laboratory of Molecular Neuropsychiatry, Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, National Scientific and Technical Research Council (CONICET), Pacheco de Melo 1854, CP 1126, Ciudad de Buenos Aires, Argentina; Institute of Ecology and Biodiversity, Faculty of Science, University of Chile, Las Palmeras 3425, Ñuñoa, Santiago, Chile.
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15
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Drug development for neurodevelopmental disorders: lessons learned from fragile X syndrome. Nat Rev Drug Discov 2017; 17:280-299. [PMID: 29217836 DOI: 10.1038/nrd.2017.221] [Citation(s) in RCA: 217] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neurodevelopmental disorders such as fragile X syndrome (FXS) result in lifelong cognitive and behavioural deficits and represent a major public health burden. FXS is the most frequent monogenic form of intellectual disability and autism, and the underlying pathophysiology linked to its causal gene, FMR1, has been the focus of intense research. Key alterations in synaptic function thought to underlie this neurodevelopmental disorder have been characterized and rescued in animal models of FXS using genetic and pharmacological approaches. These robust preclinical findings have led to the implementation of the most comprehensive drug development programme undertaken thus far for a genetically defined neurodevelopmental disorder, including phase IIb trials of metabotropic glutamate receptor 5 (mGluR5) antagonists and a phase III trial of a GABAB receptor agonist. However, none of the trials has been able to unambiguously demonstrate efficacy, and they have also highlighted the extent of the knowledge gaps in drug development for FXS and other neurodevelopmental disorders. In this Review, we examine potential issues in the previous studies and future directions for preclinical and clinical trials. FXS is at the forefront of efforts to develop drugs for neurodevelopmental disorders, and lessons learned in the process will also be important for such disorders.
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16
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Munshi K, Pawlowski K, Gonzalez-Heydrich J, Picker JD. Review of Salient Investigational Drugs for the Treatment of Fragile X Syndrome. J Child Adolesc Psychopharmacol 2017; 27:850-863. [PMID: 28475355 DOI: 10.1089/cap.2016.0200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Fragile X syndrome (FXS) is the most common inherited cause of intellectual disability, in addition to being the commonest diagnosable cause of autism. The identification of the biochemical mechanism underlying this disorder has provided amenable targets for therapy. This review aims to provide an overview of investigational drug therapies for FXS. METHODS The authors carried out a search of clinical and preclinical trials for FXS in PubMed and on the U.S. National Institutes of Health index of clinical trials ( www.clinicaltrials.gov ). We limited our review to Phase II trials or more preliminary and reviewed the associated publications for these studies, complemented by a review of the literature on PubMed. RESULTS The review of the preclinical, Phase I, and Phase II trials of agents with therapeutic potential in FXS revolves around an understanding of the putative pathways in the pathogenesis of FXS. While there is significant overlap between some of these pathways, the agents can be categorized as modulators of the metabotropic glutamate receptor system, GABAergic agents, and miscellaneous modulators affecting other pathways. CONCLUSION As trials involving agents targeting different aspects of the molecular biology proceed, common themes have emerged. With the great hope came great disappointment as the initial trials failed to demonstrate sufficient significance. In particular, the differences in outcome between the animal models and humans have highlighted the unique challenges of carrying out trials in these cognitively and behaviorally challenged individuals, as well as a dearth of clinically relevant outcome measures for use in medication trials. However, in reviewing and reframing the studies of the last decade, many important lessons have been learned, which will ultimately have a greater impact on therapeutic research in the field of developmental delay as a whole.
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Affiliation(s)
- Kaizad Munshi
- 1 Department of Psychiatry, Boston Children's Hospital , Boston, Massachusetts.,2 Harvard Medical School , Boston, Massachusetts
| | - Katherine Pawlowski
- 3 Division of Genetics and Genomics, Boston Children's Hospital , Boston, Massachusetts.,4 Division of Developmental Medicine, Department of Medicine, Boston Children's Hospital , Boston, Massachusetts
| | - Joseph Gonzalez-Heydrich
- 1 Department of Psychiatry, Boston Children's Hospital , Boston, Massachusetts.,2 Harvard Medical School , Boston, Massachusetts
| | - Jonathan D Picker
- 1 Department of Psychiatry, Boston Children's Hospital , Boston, Massachusetts.,2 Harvard Medical School , Boston, Massachusetts.,3 Division of Genetics and Genomics, Boston Children's Hospital , Boston, Massachusetts
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17
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Erickson CA, Davenport MH, Schaefer TL, Wink LK, Pedapati EV, Sweeney JA, Fitzpatrick SE, Brown WT, Budimirovic D, Hagerman RJ, Hessl D, Kaufmann WE, Berry-Kravis E. Fragile X targeted pharmacotherapy: lessons learned and future directions. J Neurodev Disord 2017; 9:7. [PMID: 28616096 PMCID: PMC5467059 DOI: 10.1186/s11689-017-9186-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 01/18/2017] [Indexed: 01/04/2023] Open
Abstract
Our understanding of fragile X syndrome (FXS) pathophysiology continues to improve and numerous potential drug targets have been identified. Yet, current prescribing practices are only symptom-based in order to manage difficult behaviors, as no drug to date is approved for the treatment of FXS. Drugs impacting a diversity of targets in the brain have been studied in recent FXS-specific clinical trials. While many drugs have focused on regulation of enhanced glutamatergic or deficient GABAergic neurotransmission, compounds studied have not been limited to these mechanisms. As a single-gene disorder, it was thought that FXS would have consistent drug targets that could be modulated with pharmacotherapy and lead to significant improvement. Unfortunately, despite promising results in FXS animal models, translational drug treatment development in FXS has largely failed. Future success in this field will depend on learning from past challenges to improve clinical trial design, choose appropriate outcome measures and age range choices, and find readily modulated drug targets. Even with many negative placebo-controlled study results, the field continues to move forward exploring both the new mechanistic drug approaches combined with ways to improve trial execution. This review summarizes the known phenotype and pathophysiology of FXS and past clinical trial rationale and results, and discusses current challenges facing the field and lessons from which to learn for future treatment development efforts.
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Affiliation(s)
- Craig A Erickson
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039 USA.,Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, OH USA
| | - Matthew H Davenport
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039 USA.,Department of Biomedical Engineering, College of Engineering and Applied Science, University of Cincinnati, Cincinnati, OH USA
| | - Tori L Schaefer
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039 USA
| | - Logan K Wink
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039 USA.,Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, OH USA
| | - Ernest V Pedapati
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039 USA.,Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, OH USA
| | - John A Sweeney
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, OH USA
| | - Sarah E Fitzpatrick
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039 USA
| | - W Ted Brown
- Institute for Basic Research in Developmental Disabilities, New York, NY USA
| | - Dejan Budimirovic
- Clinical Research Center, Clinical Trials Unit, Fragile X Clinic, Kennedy Krieger Institute, The Johns Hopkins Medical Institutions, Baltimore, MD USA.,Departments of Psychiatry & Behavioral Sciences, Child Psychiatry, The Johns Hopkins Medical Institutions, Baltimore, MD USA
| | - Randi J Hagerman
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, Davis Medical Center, University of California, Sacramento, CA USA.,Department of Pediatrics, Davis Medical Center, University of California, Sacramento, California USA
| | - David Hessl
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, Davis Medical Center, University of California, Sacramento, CA USA.,Department of Psychiatry and Behavioral Sciences, Davis Medical Center, University of California, Sacramento, California USA
| | - Walter E Kaufmann
- Greenwood Genetic Center, Greenwood, SC USA.,Boston Children's Hospital, Boston, Massachusetts USA
| | - Elizabeth Berry-Kravis
- Departments of Pediatrics, Neurological Sciences, Biochemistry, Rush University Medical Center, Chicago, Illinois USA
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18
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Jensen KB, Kirsch I, Pontén M, Rosén A, Yang K, Gollub RL, des Portes V, Kaptchuk TJ, Curie A. Certainty of genuine treatment increases drug responses among intellectually disabled patients. Neurology 2017; 88:1912-1918. [PMID: 28424273 PMCID: PMC5444309 DOI: 10.1212/wnl.0000000000003934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 02/28/2017] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine the placebo component of treatment responses in patients with intellectual disability (ID). Methods: A statistical meta-analysis comparing bias-corrected effect sizes (Hedges g) of drug responses in open-label vs placebo-controlled clinical trials was performed, as these trial types represent different certainty of receiving genuine treatment (100% vs 50%). Studies in fragile X, Down, Prader-Willi, and Williams syndrome published before June 2015 were considered. Results: Seventeen open-label trials (n = 261, 65% male; mean age 23.6 years; mean trial duration 38 weeks) and 22 placebo-controlled trials (n = 721, 62% male; mean age 17.1 years; mean trial duration 35 weeks) were included. The overall effect size from pre to post treatment in open-label studies was g = 0.602 (p = 0.001). The effect of trial type was statistically significant (p = 0.001), and revealed higher effect sizes in studies with 100% likelihood of getting active drug, compared to both the drug and placebo arm of placebo-controlled trials. We thus provide evidence for genuine placebo effects, not explainable by natural history or regression toward the mean, among patients with ID. Conclusions: Our data suggest that clinical trials in patients with severe cognitive deficits are influenced by the certainty of receiving genuine medication, and open-label design should thus not be used to evaluate the effect of pharmacologic treatments in ID, as the results will be biased by an enhanced placebo component.
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Affiliation(s)
- Karin B Jensen
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France.
| | - Irving Kirsch
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Moa Pontén
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Annelie Rosén
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Kathy Yang
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Randy L Gollub
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Vincent des Portes
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Ted J Kaptchuk
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Aurore Curie
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
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Davenport MH, Schaefer TL, Friedmann KJ, Fitzpatrick SE, Erickson CA. Pharmacotherapy for Fragile X Syndrome: Progress to Date. Drugs 2016; 76:431-45. [PMID: 26858239 DOI: 10.1007/s40265-016-0542-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
To date, no drug is approved for the treatment of Fragile X Syndrome (FXS) although many drugs are used to manage challenging behaviors from a symptomatic perspective in this population. While our understanding of FXS pathophysiology is expanding, efforts to devise targeted FXS-specific treatments have had limited success in placebo-controlled trials. Compounds aimed at rectifying excessive glutamate and deficient gamma-aminobutyric acid (GABA) neurotransmission, as well as other signaling pathways known to be affected by Fragile X Mental Retardation Protein (FMRP) are under various phases of development in FXS. With the failure of several metabotropic glutamate receptor subtype 5 (mGlur5) selective antagonists under clinical investigation, no clear single treatment appears to be greatly effective. These recent challenges call into question various aspects of clinical study design in FXS. More objective outcome measures are under development and validation. Future trials will likely be aimed at correcting multiple pathways known to be disrupted by the loss of FMRP. This review offers a brief summary of the prevalence, phenotypic characteristics, genetic causes and molecular functions of FMRP in the brain (as these have been extensively reviewed elsewhere), discusses the most recent finding in FXS drug development, and summarizes FXS trials utilizing symptomatic treatment.
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Affiliation(s)
- Matthew H Davenport
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3039, USA
- Department of Biomedical Engineering, College of Engineering and Applied Science, University of Cincinnati, Cincinnati, OH, 45221, USA
| | - Tori L Schaefer
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3039, USA
| | - Katherine J Friedmann
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3039, USA
| | | | - Craig A Erickson
- Division of Child and Adolescent Psychiatry (MLC 4002), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3039, USA.
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Abstract
Fragile X syndrome (FXS) is the most common inherited form of intellectual disability, and is the leading single-gene cause of autism spectrum disorders. It is due to a loss of the fragile X mental retardation protein, which leads to molecular, behavioral, and cognitive deficits in these patients. Improvements in our understanding of its pathophysiology have led to the development of numerous targeted treatments in FXS as highlighted by metabotropic glutamate receptor antagonists and gamma-Aminobutyric acid receptor modulators. This review will summarize relevant pre-clinical data and results from clinical trials in human subjects with FXS. It will also highlight upcoming studies and future directions for clinical trials as well.
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Affiliation(s)
- Andrew Ligsay
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, Sacramento, CA, USA
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Randi J Hagerman
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, Sacramento, CA, USA
- Department of Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA
- Address correspondence to: Dr. Randi J Hagerman, Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis Medical Center, 2825 50th Street, Sacramento, CA 95817, USA. E-mail:
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Abstract
PURPOSE OF REVIEW Psychotropic medications are commonly prescribed to people with intellectual disability. We reviewed current evidence-based pharmacotherapy options and recent updates to guide clinicians in their medication management plans. RECENT FINDINGS Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors in children with intellectual disability. Evidence in adults is inconclusive. Methylphenidate appears to be effective, and α-agonists appear promising in reducing attention-deficit hyperactivity disorder symptoms. Lithium might be effective in reducing aggression. Evidence is limited to support the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors. Antidepressants may be poorly tolerated and might not be effective in reducing repetitive/stereotypic behaviors.In recent trials, glutamatergic and GABAergic agents for fragile X syndrome, and acetylcholinesterase inhibitors for Down's syndrome, failed to show efficacy. Growth hormone treatment might improve cognition and behavior in Prader-Willi syndrome population. Results from oxytocin trials on social behaviors are inconclusive albeit promising. Melatonin appears to improve sleep. Most trials of dietary supplements did not show benefits. SUMMARY Evidence-based pharmacotherapy options in people with intellectual disability are limited, and many agents can cause substantial adverse events. For this reason, clinicians should consider pharmacotherapy as only a part of comprehensive treatment, and regularly assess drug effects, adverse events, and the feasibility of decreasing dose or withdrawing medications.
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Kazdoba TM, Leach PT, Yang M, Silverman JL, Solomon M, Crawley JN. Translational Mouse Models of Autism: Advancing Toward Pharmacological Therapeutics. Curr Top Behav Neurosci 2016; 28:1-52. [PMID: 27305922 PMCID: PMC5116923 DOI: 10.1007/7854_2015_5003] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Animal models provide preclinical tools to investigate the causal role of genetic mutations and environmental factors in the etiology of autism spectrum disorder (ASD). Knockout and humanized knock-in mice, and more recently knockout rats, have been generated for many of the de novo single gene mutations and copy number variants (CNVs) detected in ASD and comorbid neurodevelopmental disorders. Mouse models incorporating genetic and environmental manipulations have been employed for preclinical testing of hypothesis-driven pharmacological targets, to begin to develop treatments for the diagnostic and associated symptoms of autism. In this review, we summarize rodent behavioral assays relevant to the core features of autism, preclinical and clinical evaluations of pharmacological interventions, and strategies to improve the translational value of rodent models of autism.
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Affiliation(s)
- Tatiana M Kazdoba
- MIND Institute, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Room 1001A Research 2 Building 96, 4625 2nd Avenue, Sacramento, CA 95817, USA
| | - Prescott T Leach
- MIND Institute, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Room 1001A Research 2 Building 96, 4625 2nd Avenue, Sacramento, CA 95817, USA
| | - Mu Yang
- MIND Institute, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Room 1001A Research 2 Building 96, 4625 2nd Avenue, Sacramento, CA 95817, USA
| | - Jill L Silverman
- MIND Institute, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Room 1001A Research 2 Building 96, 4625 2nd Avenue, Sacramento, CA 95817, USA
| | - Marjorie Solomon
- MIND Institute, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Room 1001A Research 2 Building 96, 4625 2nd Avenue, Sacramento, CA 95817, USA
| | - Jacqueline N Crawley
- MIND Institute, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Room 1001A Research 2 Building 96, 4625 2nd Avenue, Sacramento, CA 95817, USA.
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Curie A, Yang K, Kirsch I, Gollub RL, des Portes V, Kaptchuk TJ, Jensen KB. Placebo Responses in Genetically Determined Intellectual Disability: A Meta-Analysis. PLoS One 2015; 10:e0133316. [PMID: 26226597 PMCID: PMC4520690 DOI: 10.1371/journal.pone.0133316] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/25/2015] [Indexed: 12/01/2022] Open
Abstract
Background Genetically determined Intellectual Disability (ID) is an intractable condition that involves severe impairment of mental abilities such as learning, reasoning and predicting the future. As of today, little is known about the placebo response in patients with ID. Objective To determine if placebo response exists in patients with genetically determined ID. Data sources and Study selection We searched Medline/PubMed, EMBASE, CENTRAL and PsycINFO to find all placebo-controlled double-blind randomized clinical trials (RCTs) in patients with genetically determined ID, published up to April 2013, focusing on core ID symptoms. Data extraction and synthesis Two investigators extracted outcome data independently. Main outcomes and measures Bias-corrected standardized mean difference (Hedge’s g) was computed for each outcome measure, using the Comprehensive Meta-Analysis software. A priori defined patient sub-groups were analyzed using a mixed-effect model. The relationship between pre-defined continuous variable moderators (age, IQ, year of publication and trial duration) and effect size was analyzed using meta-regression Results Twenty-two placebo-controlled double-blind RCTs met the inclusion criteria (n = 721, mean age = 17.1 years, 62% men, mean trial duration = 35 weeks). There was a significant overall placebo response from pre- to post-treatment in patients with ID (g = 0.468, p = 0.002), both for “subjective outcomes” (a third-person’s evaluation of the patient) (g = 0.563, p = 0.022) and “objective outcomes” (direct evaluation of the patient’s abilities) (g = 0.434, p = 0.036). Individuals with higher IQ had higher response to placebo (p = 0.02) and no placebo response was observed in ID patients with comorbid dementia. A significant effect of age (p = 0.02) was found, indicating higher placebo responses in treatment of younger patients. Conclusions and relevance Results suggest that patients with genetically determined ID improve in the placebo arm of RCTs. Several mechanisms may contribute to placebo effects in ID, including expectancy, implicit learning and “placebo-by-proxy” induced by clinicians/family members. As the condition is refractory, there is little risk that improvements are explained by spontaneous remission. While new avenues for treatment of genetically determined ID are emerging, our results demonstrate how contextual factors can affect clinical outcomes and emphasize the importance of being vigilant on the role of placebos when testing novel treatments in ID.
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Affiliation(s)
- Aurore Curie
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
- L2C2, Institut des Sciences Cognitives, CNRS UMR5304, Bron, France
- Centre de Référence Déficiences Intellectuelles de Causes Rares, Hôpital Femmes Mères Enfants, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon1, Lyon, France
- EPICIME-CIC1407/INSERM, Bron, France
- * E-mail:
| | - Kathy Yang
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
- School of Psychology, Plymouth University, Plymouth, United Kingdom
| | - Randy L. Gollub
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
| | - Vincent des Portes
- L2C2, Institut des Sciences Cognitives, CNRS UMR5304, Bron, France
- Centre de Référence Déficiences Intellectuelles de Causes Rares, Hôpital Femmes Mères Enfants, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon1, Lyon, France
| | - Ted J. Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Karin B. Jensen
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Schaefer TL, Davenport MH, Erickson CA. Emerging pharmacologic treatment options for fragile X syndrome. APPLICATION OF CLINICAL GENETICS 2015; 8:75-93. [PMID: 25897255 PMCID: PMC4396424 DOI: 10.2147/tacg.s35673] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Fragile X syndrome (FXS) is the most common single gene cause of intellectual disability and autism spectrum disorder. Caused by a silenced fragile X mental retardation 1 gene and the subsequent deficiency in fragile X mental retardation protein, patients with FXS experience a range of physical, behavioral, and intellectual debilitations. The FXS field, as a whole, has recently met with some challenges, as several targeted clinical trials with high expectations of success have failed to elucidate significant improvements in a variety of symptom domains. As new clinical trials in FXS are planned, there has been much discussion about the use of the commonly used clinical outcome measures, as well as study design considerations, patient stratification, and optimal age range for treatment. The evidence that modification of these drug targets and use of these failed compounds would prove to be efficacious in human clinical study were rooted in years of basic and translational research. There are questions arising as to the use of the mouse models for studying FXS treatment development. This issue is twofold: many of the symptom domains and molecular and biochemical changes assessed and indicative of efficacy in mouse model study are not easily amenable to clinical trials in people with FXS because of the intolerability of the testing paradigm or a lack of noninvasive techniques (prepulse inhibition, sensory hypersensitivity, startle reactivity, or electrophysiologic, biochemical, or structural changes in the brain); and capturing subtle yet meaningful changes in symptom domains such as sociability, anxiety, and hyperactivity in human FXS clinical trials is challenging with the currently used measures (typically parent/caregiver rating scales). Clinicians, researchers, and the pharmaceutical industry have all had to take a step back and critically evaluate the way we think about how to best optimize future investigations into pharmacologic FXS treatments. As new clinical trials are coming down the drug discovery pipeline, it is clear that the field is moving in a direction that values the development of molecular biomarkers, less subjective quantitative measures of symptom improvement, and rating scales developed specifically for use in FXS in conjunction with drug safety. While summarizing preclinical evidence, where applicable, and discussing challenges in FXS treatment development, this review details both completed clinical trials for the targeted and symptomatic treatment of FXS and introduces novel projects on the cusp of clinical trial investigation.
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Affiliation(s)
- Tori L Schaefer
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew H Davenport
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Craig A Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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de Esch CE, Zeidler S, Willemsen R. Translational endpoints in fragile X syndrome. Neurosci Biobehav Rev 2014; 46 Pt 2:256-69. [DOI: 10.1016/j.neubiorev.2013.10.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/07/2013] [Accepted: 10/09/2013] [Indexed: 01/01/2023]
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de Diego-Otero Y, Calvo-Medina R, Quintero-Navarro C, Sánchez-Salido L, García-Guirado F, del Arco-Herrera I, Fernández-Carvajal I, Ferrando-Lucas T, Caballero-Andaluz R, Pérez-Costillas L. A combination of ascorbic acid and α-tocopherol to test the effectiveness and safety in the fragile X syndrome: study protocol for a phase II, randomized, placebo-controlled trial. Trials 2014; 15:345. [PMID: 25187257 PMCID: PMC4168067 DOI: 10.1186/1745-6215-15-345] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 07/18/2014] [Indexed: 01/18/2023] Open
Abstract
Background Fragile X syndrome (FXS) is an inherited neurodevelopmental condition characterised by behavioural, learning disabilities, phisical and neurological symptoms. In addition, an important degree of comorbidity with autism is also present. Considered a rare disorder affecting both genders, it first becomes apparent during childhood with displays of language delay and behavioural symptoms. Main aim: To show whether the combination of 10 mg/kg/day of ascorbic acid (vitamin C) and 10 mg/kg/day of α-tocopherol (vitamin E) reduces FXS symptoms among male patients ages 6 to 18 years compared to placebo treatment, as measured on the standardized rating scales at baseline, and after 12 and 24 weeks of treatment. Secondary aims: To assess the safety of the treatment. To describe behavioural and cognitive changes revealed by the Developmental Behaviour Checklist Short Form (DBC-P24) and the Wechsler Intelligence Scale for Children–Revised. To describe metabolic changes revealed by blood analysis. To measure treatment impact at home and in an academic environment. Methods/Design A phase II randomized, double-blind pilot clinical trial. Scope: male children and adolescents diagnosed with FXS, in accordance with a standardized molecular biology test, who met all the inclusion criteria and none of the exclusion criteria. Instrumentation: clinical data, blood analysis, Wechsler Intelligence Scale for Children–Revised, Conners parent and teacher rating scale scores and the DBC-P24 results will be obtained at the baseline (t0). Follow up examinations will take place at 12 weeks (t1) and 24 weeks (t2) of treatment. Discussion A limited number of clinical trials have been carried out on children with FXS, but more are necessary as current treatment possibilities are insufficient and often provoke side effects. In the present study, we sought to overcome possible methodological problems by conducting a phase II pilot study in order to calculate the relevant statistical parameters and determine the safety of the proposed treatment. The results will provide evidence to improve hyperactivity control and reduce behavioural and learning problems using ascorbic acid (vitamin C) and α-tocopherol (vitamin E). The study protocol was approved by the Regional Government Committee for Clinical Trials in Andalusia and the Spanish agency for drugs and health products. Trial registration ClinicalTrials.gov Identifier: NCT01329770 (29 March 2011)
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Affiliation(s)
- Yolanda de Diego-Otero
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Civil, Pabellón 2 bajo, Plaza del Hospital Civil S/N, 29009 Málaga, Spain.
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Garlich FM, Balakrishnan K, Shah SK, Howland MA, Fong J, Nelson LS. Prolonged altered mental status and bradycardia following pediatric donepezil ingestion. Clin Toxicol (Phila) 2014; 52:291-4. [DOI: 10.3109/15563650.2014.900182] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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